Evaluation of Vertigo

Management of Sensations Involving Spinning, Swaying, or Tilting

Jul 25, 2009 Anthony Lee

How does a physician handle a patient who presents with vertigo?

Vertigo is a symptom involving illusory movement, which can be described as a sensation of spinning, swaying, or tilting. Patients may sometimes refer to this phenomenon as dizziness, but the term is a broad category that encompasses vertigo from vestibular dysfunction, lightheadedness from insufficient blood circulation to the brain, and imbalance from defects in coordination. Generally, vertigo is a worrisome symptom that can sometimes indicate the presence of a serious condition.

Etiology and Pathophysiology

The vestibular system consists of two types of organs. The semicircular canals sense rotational motion, and a disorder of these organs causes one to perceive spinning. The otolith organs sense linear motion and, when dysfunctional, are involved in sensations of swaying and tilting. Vertigo can also result from conditions that disrupt the relay of signals from the vestibular system to the brain.

Consequently, vertigo can be categorized as follows:

Peripheral Vertigo: Peripheral vertigo occurs secondary to disorders of the vestibular system its nerves pathways to the central nervous system. Causes of peripheral vertigo include benign paroxysmal positional vertigo from dislodged otolith particles, Meniere’s disease with excess fluid pressure in the inner ear, a viral or postviral inflammatory disorder affecting the vestibulocochlear nerve (labyrinthitis), ototoxicity from aminoglycoside antibiotics, and acoustic neuroma.
Central Vertigo: Central vertigo is the result of abnormalities in the brainstem or cerebellum. This may occur due to conditions such as a transient ischemic attack, stroke, hemorrhage, and multiple sclerosis.

Evaluation

Individuals with vertigo perceive self-motion or environmental motion as spinning, swaying, or tilting. This may be a one-time event or a set of recurrent episodes that last seconds to days. Vertigo is always worsened with head movement and may be associated with nausea, vomiting, and manifestations related to the underlying cause, such as focal neurological deficits with stroke.

Besides information from the patient history, a physician may perform a physical exam, which may reveal nystagmus, or a rhythmic oscillation of the eyes. As part of the physical exam, the physician may perform the Dix-Hallpike maneuver, involving head turning and body position changes to elicit vertigo and nystagmus. Other tests include head-shaking tests to evaluate eye fixation, caloric testing with irrigation of each ear with warm or cold water, computed tomography (CT) or magnetic resonance imaging (MRI) to rule out brain lesions, and electronystagmography (ENG) or videonystagmography (VNG) to further assess eye movements.

Treatment

The treatment of vertigo involves addressing the underlying cause, if possible. For symptomatic relief of vertigo, patients may take medications, such as anticholinergics, antihistamines, phenothiazines, and benzodiazepines. In some cases, vestibular rehabilitation can train the patient to adapt to vertigo through balance exercises.

References

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